1. Deep cervical space infections
Yaser Baroud

2. Infection of deep cervical fascial spaces is uncommon, but serious.!!!
Infection of the deep fascial spaces of the neck can compress, deviate, or completely obstruct the airway, and invade vital structures such as the major vessels, and mediastinum.

3. Lateral pharyngeal space
Extends from the base of the skull at the sphenoid bone to the hyoid bone inferiorly.
Medial to the medial pterygoid muscle and lateral to the superior pharyngeal constrictor muscle.
The space is bounded anteriorly by the pterygomandibular raphe and extends posteromedially to the retropharyngeal space.

4. Lateral pharyngeal space
The styloid process and associated muscles and fascia divide the lateral pharyngeal space into an:
Anterior compartment, which contains primarily loose connective tissue.
Posterior compartment, which contains the carotid sheath and cranial nerves IX (glossopharyngeal), X (vagus), and XII (hypoglossal).

5. Lateral pharyngeal space
Clinical findings:
Trismus ??
Lateral swelling of the neck
Dysphagia
Malaised patient
Deviated head

6. Lateral pharyngeal space
Complications:
Thrmobosis of the internal jagular vein
Erosion of the carotid artery and its branches
Interference with the 9, 10, 12 cranial nerves.
Progression to the retropharyngeal space.

7. Retropharyngeal space
Bounded anteriorly by the pharyngeal constrictor muscles and the retropharyngeal fascia, and posteriorly by the alar fascia.
Begins at the base of the skull and ends inferiorly at a variable point between (C6) and (T4) vertebrae.

8. Lateral pharyngeal space
**Contains only loose connective tissue and lymph nodes, so it provides little barrier to the spread of infection from one lateral pharyngeal space to the other to encircle the airway.
** Infection can rupture the alar fascia and enter the danger space.

9. Danger space
lies between the alar fascia anteriorly and the prevertebral fascia posteriorly.
The danger space extends from the base of the skull to the diaphragm, and it is continuous with the posterior mediastinum.

10. Prevertebral space
The prevertebral space is rarely involved in odontogenic infections because the prevertebral fascia fuses with the periosteum of the vertebral bodies.
Prevertebral space infections are usually caused by osteomyelitis of the vertebrae.

11. Mediastinium The mediastinum is the space between the lungs.
It contains the heart, the phrenic and vagus nerves, the trachea and the main stem bronchi, the esophagus, and the great vessels, including the aorta and the inferior and superior vena cava.
Mediastinal infection may compress the heart and lungs, rupture in to the lungs and trachea, and spread to the abdominal cavity.
Mortality is high.

12. Necrotizing fasciitis “flesh-eating bacteria”
Rapid spread of infection on the superficial surface of the anterior, or investing, layer of the deep cervical fascia, just deep to the platysma muscle.
Necrosis of the overlying platysma, subcutaneous tissue, and skin occurs.
Ischemia leads to vesicles and dusky purple discoloration.

13. Necrotizing fasciitis
Management :
Surgical debridement
High dose broad spectrum antibiotics
Control of underlying medical conditions
Correction of fluids and electrolytes

15. Management of fascial space infections

16. Surgery…..surgery……surgery
Airway security is the prime concern in the management of severe odontogenic infections.
Medical management of the patient with a serious infection must include a thorough assessment and support of host defense mechanisms, including analgesics, fluid requirements, and nutrition.
High-dose bactericidal antibiotics are necessary.
Surgery…..surgery……surgery
Be generous !!

17. An infection in the cellulitis stage will resolve more rapidly if incised and drained.
Aggressive surgical exploration is still the primary method of therapy for serious odontogenic infections of the head and neck.

19. Osteomyelitis Litterly, Ostemyelitis = inflammation of the bone marrow
Clincally, Osteomelitis = infection of bone
Osteomyelitis usually begins in the medullary cavity, involving cancellous bone, then it extends and spreads to cortical bone and eventually to the periosteum.
Invasion of bacteria into cancellous bone causes soft
tissue inflammation and edema within the closed bony marrow spaces.

20. Osteomyelitis
Soft tissue edema that is enclosed by calcified tissue results in increased tissue hydrostatic pressure that rises above the blood pressure of the feeding arterial vessels causing soft tissue necrosis.
Impaired circulation by pressure results in bacterial proliferation. ?!
Mandible is affected more than maxilla, because the blood supply of maxilla is much richer and bone is thinner .
Rarely happens in immunocompetent patients.

21. History ?? Osteomyelitis
Primary bacteria of concern are similar to those causing odontogenic infections.
History ??

22. Osteomyelitis
Acute suppurative osteomyelitis :Show little or no radiographic changes.
Chronic osteomyelitis:
Demonstrates bony destruction at area of infection.
Uniform radiolucency or moth-eaten appearance.
Areas of radiopacities also may occur within the radilucency (squestrum)

23. **Squestrum: Islands of bone that have not been resorbed.

24. Treatment of osteomyelitis
Osteomyelitis is treated medically as well as surgically.
Surgical débridement (removal of infected teeth, necrotic none) , removal of causative factors, and appropriate antibiotics.
Corticotomy (removal or perforation of the bony cortex) and excision of necrotic bone (until actively bleeding bone tissue is encountered) may be necessary.

25. Treatment of osteomyelitis
Antibiotics should be continued for a much longer time than is usual for odontogenic infections. (6 weeks-6 monthes).
**Actinomycotic osteomyelitis:
Has a propensity to recur after long, symptom-free intervals.

26. Actimomycosis
Uncommon infection of the hard and soft tissues of the head and neck.
Actinomycosis is usually caused by Actinomyces israelii (anaerobic bacteria).
Soft and hard tissues may be affected.
Infection does not follow anatomical planes but burrow through them forming lobular mass
(psuedotumor).
Multiple cutaneous sinus tracts develop.

27. The diagnosis is often made on histopathologic examination of a pus specimen because of the presence of typical colonies of actinomyces that look like sulfur granules within the exudate.

28. Actinomycosis Treatment : Incision and drainage Antibiotics
Excision of all sinus tracts
**Penicillin is the antibiotic of choice.
**This microorganism lies dormant in the oral cavity and may become activated under certain circumstances.

29. Candidiasis Candida Albicans Occur in immunocompromised patients.
Psuedomembranous candidiasis:
White patches that are easly rubbed off.
Erythematous candidiasis:
Appear as raw surface or loss of filiform papillae of the tongue
Angular cheilitis:
White or ulcerated patches at the corner of the mouth

30. Candidiasis Treatment: Topical antifungal agents ( nystatin)
Potent IV antifungal agents for immunocompromised patients.